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THE  CURE  OF  THE  MQRE  DIFFICULT  AS 

WELL  AS  THE  SIMPLER  INGUINAL 

RUPTURES 


W.  S.  HALSTED,  M.  D. 

Surgeon  in-^hief  to  the  Johns  Hopkins  Hospital,  Professor  of  Surgery  in  the 
Johns  Hopkins  University 


Reprinted  from  The  Johns  Hopkins  Hospital  Bulletin,   No.    149,  August,    1903 


ZU  ^oxi>  Q0afttinovc  (preee 

THE    I'KIEUICNWALU   COMPANY 
ISALTIMOKE,  MU. 

1903 


^/tt^-v^^^L-t^v^   Cij^^ciltJ^j^^, 


H'6 


[From  The  Johns  Hopkins  Hospital,  Bulletin,  Vol.  XIV,  No.  149, 
August,  1903.] 


THE  CURE  OF  THE  MORE  DIFFICULT  AS  WELL  AS 
THE  SIMPLER  INGUINAL  RUPTURES. 

By  W.  S.  Halsted,  M.D., 
Surgeon-in-Chief,  The  Johns  Hopkins  Hospital. 

This  communication  will,  I  hope,  be  of  interest  to  friends  [2081 
who  have  asked  for  precise  information  as  to  the  modifications 
which  our  operation  for  hernia  has  undergone  in  the  process 
of  development  during  the  past  thirteen  years,  and  of  service 
to  operators  who  seek  to  obtain  in  each  instance  a  result  as 
perfect  as  possible  and  who  recognize  that  not  infrequently 
there  occur  cases  of  hernia  requiring  for  their  cure  extraor- 
dinary operative  procedures.  The  present  operation  has  been 
evolved  by  degrees  and  stands  for  the  experience  of  14  years 
derived  from  more  than  1000  operations  for  the  cure  of  in- 
guinal hernia ;  features  of  the  old  where  they  seemed  unneces- 
sary have  been  dropped  and  new  ones,  as  they  seemed  to  be 
indicated,  added.  To  record  even  the  cruder  general  results 
of  so  many  operations  (upon  adults  with  few  exceptions)*  for 
the  cure  of  inguinal  hernia  are  required  special  training,  some 


1  The  value  of  an  operation  for  the  cure  of  inguinal  hernia  can  hardly 
be  determined  upon  children  for  the  surgeon  is  greatly  assisted  by  nature 
as  the  child  develops,  and  he  is  not  confronted  with  the  more  difficult 
problems  arising  from  an  undeveloped  or  an  acquired  atrophy  of  the 
conjoined  tendon,  or  from  fatty  degeneration  and  atrophy  of  the  inter- 
nal oblique  muscle.  Furthermore,  the  recurrences  have  almost  invari- 
ably followed  operations  for  the  cure  of  very  large  and  old  ruptures, 
such  as  are  impossible  in  children.  And  to  quote  from  Bloodgood, 
"As  we  have  had  no  recurrences"  in  children  "  whether  the  veins  have 
been  excised  or  not,  it  does  not  seem  to  make  much  diflerence  what 
is  done  with  the  very  small  cord." 

(1) 


[308]  zeal  and  a  particular  honesty  of  purpose ;  and  for  the  recogni- 
tion and  interpretation  of  the  nicer  facts,  keen  perception  and 
fine  tactile  sense  are  indispensable.  A  few  drops  or  even  a 
dram  of  fluid  in  the  tunica  vaginalis  might  readily  escape  de- 
tection, and  to  determine  slight  swelling  or  induration  here 
and  there  in  the  epididymis  and  the  relative  size  of  the  two 
testicles  may  be  difficult.  A  novice  can  usually  discover  a  dis- 
tinct recurrence  and  so  can  the  patient,  but  I  have  known  an 
eminent  surgeon  to  overlook  a  weakness  in  a  scar  of  his  own 
making  sufficient  to  constitute,  without  doubt,  a  recurrence. 
The  surgeon  is  fortunate  and  likely  to  be  true  to  himself 
whose  observations  are  controlled  by  mature  assistants  with 
large  experience  in  the  operative  treatment  of  hernia  and 
who  are  as  eager  as  he  to  ascertain  and  state  the  exact  truth. 
If  our  operation  for  the  radical  cure  of  inguinal  hernia  has 
improved,  it  is  due  in  no  small  measure  to  the  arduous  labors 
of  Dr.  Bloodgood,  whose  valuable  contribution'  should  be 
better  known.  He  established  several  facts  of  prime  import- 
ance from  his  study  of  our  first  300  cases  of  inguinal  hernia. 
The  majority  of  inguinal  ruptures  are  now  easily  and  quite 
well  cured  by  a  variety  of  procedures  and  by  the  average  oper- 
ator, hence  it  is  difficult  for  the  student  and  young  practi- 
tioner to  comprehend  that  it  is  hardly  more  than  a  decade  since 
this  variety  of  hernia  completely  baffled  the  efforts  of  the  best 
surgeons  to  cure  it.  That  so  simple  an  operation  as  Kocher's 
can  cure  perhaps  many  of  the  milder  ruptures,  provided  the 
neck  of  the  sac  is  not  too  wide,  leads  to  the  inquiry  whether 
the  features,  of  these  operations,  upon  which  most  stress  has 
been  laid  may  not  be  relatively  unimportant,  since  operations 
of  the  magnitude  of  Bassini's  and  the  author's  are  not  in  all 
cases  indispensable.  If  the  transplantation  of  tlie  neck  of 
the  sac  can  cure  so  many  cases,  is  it  not  possible  that  the  trans- 
plantation of  the  cord,  which  at  first  was  deemed  so  essential 
by  Bassini  and  the  author,  may  have  owed  its  success  in  part 
to  the  fact  that  it  made  possible  this  very  high  closure  of  the 
sac's  neck?  Although  for  several  years  our  operation,  so  far 
as  transplantation  of  the  cord  and  high  closure  of  the  sac  is 


« Johns  Hopkins  Hospital  Reports,  vol.  vii. 

(2) 


concerned,  was  even  more  radical  than  Bassini's  (the  cord  was  [308] 
transplanted  into  the  substance  of  the  divided  internal  oblique 
muscle),  we  were  tempted,  at  the  very  outset,  to  test  the  rela- 
tive value  of  cord  transplantation  in  some  of  the  cases,  and 
permitted  the  entire  cord  to  lie  undislocated  and  altogether 
undisturbed  in  its  bed  and  to  trust  to  the  suture  of  the  inter- 
nal oblique  muscle  to  Poupart's  ligament,  to  the  "lining  of 
the  wound  with  muscle  "  to  efEect  a  cure.  It  was  well  wor- 
thy of  note,  as  Bloodgood  emphasizes  in  his  article,  that  all  of 
the  cases  treated  in  this  manner  (cord  undisturbed)  remained 
cured.  Another  fact  which  Bloodgood's  painstaking  study 
established  was  that  of  one  hundred  and  nine  cases  in  which 
the  larger  bundle  of  veins  of  the  cord  was  excised  and  the  heal- 
ing was  per  primam,  not  one  showed  a  recurrence  or  any  weak- 
ness at  the  site  of  the  transplanted  vas  deferens,  whereas  in 
6.4  per  cent  of  the  cases  which  healed  by  first  intention  and 
in  which  the  veins  had  not  been  excised,  there  was  a  recurrence 
at  the  upper  angle  of  the  wound,  at  the  site  of  the  trans- 
planted cord.  And  even  in  the  wounds  which  suppurated, 
there  was  not  a  recurrence  in  the  nine  cases  of  vein  excision, 
whereas,  of  eleven  suppurating  cases  in  which  the  cord-veins 
were  not  excised,  four  (36.3  per  cent)  recurred.  In  118 
cases,  therefore,  in  which  the  larger  bundle  of  veins  was  ex- 
cised there  was  no  recurrence  at  the  site  of  the  transplanted 
cord  whether  suppuration '  occurred  or  not.     And,  certainly. 


3  Nine  suppurations  in  118  cases,  and  for  most  of  wliich  the  author 
was  personally  responsible,  seems  a  large  percentage  (7.6^)  even  for 
hernia  cases  ten  years  ago,  but  it  was  considered  a  good  showing  in 
those  days.  Since  every  one,  including  the  operator,  has  invariably 
worn  rubber  gloves,  suppurations  even  in  the  operations  for  hernia,  has 
occurred  in  probably  less  than  1^  of  the  cases.  In  1890,  all  the  assis- 
tants at  an  operation,  the  nurses  and  physicians,  systematically  wore 
gloves,  bat  the  operator  wore  them  only  for  special  operations,  such  as 
exploratory  laparotomies,  explorations  for  foreign  bodies,  loose  carti- 
lages, etc.,  in  the  joints,  suture  of  the  fractured  patella,  etc.— in  other 
words,  when  there  was  a  possibility  of  doing  serious  harm  and  no  cer- 
tainty of  doing  great  good.  By  degrees  the  operator  wore  gloves  more 
frequently,  until  Dr.  Bloodgood  as  Resident  Surgeon,  and  who  had  become 
thoroughly  accustomed  to  them  as  assistant,  wore  them  invariably  as 
operator  and  demonstrated  from  our  statistics  the  necessity  of  doing  so. 
It  seems  to  be  a  fact  that  one  who  has  been  trained  to  operate  always 

(3) 


1.209]  the  eases  in  which  the  veins  were  excised,  were  not  the  simpler 
ones. 

One  of  xhe  most  important  of  the  facts  ascertained  by 
Bloodgood  was  the  great  variation  in  the  width  of  the  con- 
joined tendon  and  the  responsibility  of  the  insufficient  tendon 
for  the  recurrences  at  the  lower  angle  of  the  wound,  through 
the  external  ring,  direct.  The  transplantation  of  the  rectus 
muscle  recommended  by  Bloodgood  *  to  close  this  defect  seems 
to  accomplish  Avhat  its  originator  hoped  it  might,  although, 
a  priori,  one  would  fear  that  this  powerful  straight  muscle 
must  eventuaJlly  djraw  away  from  Poupart's  ligament  to 
which  it  had  been  sewed.  Is  it  not  conceivable,  however,  that 
a,  new  encompassing  fascia  may  develop  about  a  transplanted 
muscle  and  that  this  fascia  may  remain  even  after  the  muscle 
has  been  pulled  away?  Experiments  upon  animals  to  deter- 
mine this  point  would  be  interesting.  M.  Holl,  now  Professor 
of  Anatomy  in  Gratz,  directed  attention  many  years  ago  to  the 
part  muscles  probably  play  in  the  determination  and  develop- 
ment of  the  fasciae. 

Hence,  so  long  ago  as  1896  we  recognized,  thanks  to  Blood- 


in  rubber  gloves  finds  it  awkward  to  operate  without  them.  I  have 
more  than  once  heard  my  assistants,  while  performing  some  insignificant 
operation  without  them,  call  for  gloves  because,  as  they  said,  they  were 
conscious  of  unnatural  finger  movements,  of  a  certain  clumsiness  with- 
out them.  With  gloves  one  probably  acquires  special  methods  of  tying 
knots,  holding  instruments,  etc.  In  our  clinic  the  heavier  gloves  are 
exclusively  used,  although  probably  every  member  of  the  Staff  has  by 
predisposition  been  in  favor  of  the  thinner  gloves  and  had  to  convince 
himself  by  trial  of  the  thinner  varieties  that  the  thick  ones,  even  with 
seams  on  the  fingers,  were  preferable.  The  thin  gloves  were  too  slip- 
pery ;  also  too  unsafe,  chiefly  because  of  the  danger  of  minute  unde- 
tected holes.  Cotton  gloves,  if  changed  very  frequently,  are  undoubt- 
edly better  than  no  gloves  at  all.  If  the  operator  desires  the  physical 
property  of  the  cotton  which  enables  him  to  hold  more  securely  and 
handle  with  more  precision  the  intestines  and  viscera  he  might  wear  a 
very  delicate  gauze-mesh  glove  over  the  rubber  or  over  two  or  three 
fingers  of  the  rubber  glove.  Possibly  a  rubber  glove  might  be  manu- 
factured with  a  wide  gauze  mesh  permanently  imbedded  in  its  palmar 
surface. 

■•Anton    Wofler,    Beitrage    zur    klinischen    Chirurgie    (Festschrift   f. 
Billroth),  1893. 

(4) 


good,  the  value  of  the  excision  of  the  veins  of  the  cord  and  the  [209] 
necessity  for  paying  more  attention  to  the  neglected  lower  angle 
of  the  wound.  Naturally,  it  was  primarily  to  the  upper  angle 
that  we  had  devoted  our  thoughts,  for,  as  emphasized  in  one 
of  the  author's  articles  on  the  subject,  "  the  cord  is  the  first 
cause  of  the  hernia  and  the  ultimate  obstacle  to  its  cure."' 
And  this  is  true,  notwithstanding  the  fact  that  recurrences  at 
the  lower  angle  were  at  first  not  very  rare ;  for,  our  attention 
having  been  called  to  these  lower  angle  recurrences,  methods 
to  cure  them  were  soon  found. 

The  success  attending  excision  of  the  veins  (one  hundred 
and  eighteen  cases  without  recurrence  at  the  site  of  the  trans- 
planted vas  deferens)  seemed  to  justify  a  continuance  of  this 
practice,  provided  it  occasioned  no  undesirable  results;  but 
excision  of  the  veins  with  transplantation  of  the  vas  deferens 
taught  us  that,  not  infrequently,  a  hydrocele,  usually  insig- 
nificant in  size,  was  to  be  expected,  and  that  in  about  10  per 
cent  of  the  cases  atrophy  of  the  testicle  had  occurred.  x\tro- 
phy  of  this  organ,  however,  was  observed  only  in  cases  com- 
plicated by  a  very  considerable  swelling  of  the  epididymis, 
and  this  observation  of  Bloodgood's,  made  so  many  years 
ago,  has  been  verified  by  our  study  of  more  than  one 
thousand  operations.  Great  care  was  exercised,  therefore, 
in  excising  the  veins  and,  for  a  short  time,  a  few  months 
perhaps,  this  procedure  was  not  so  invariably  practiced  by  all 
of  us,  being  reserved  for  cases  which  seemed  imperatively  to 
demand  it.  We  formerly  handled  the  cord  as,  I  presume, 
almost  everyone  still  does;  separated  it,  more  or  less  roughly, 
by  tearing,  from  the  sac  and  its  enveloping  membranes,  and 
raised  it  on  a  hook  or  strip  of  gauze  preparatory  to  transplan- 
tation and  while  the  stitches  were  being  applied.  We  now 
treat  the  vas  deferens  with  great  deference,  thanks  again  to 
Bloodgood.     (Vide  description  of  operation  below.) 

It  occurred  to  Bloodgood  before  the  publication  of  his  report 
on  hernia  that  it  might  be  well  to  split  the  cord,  transplanting 
only  the  veins  to  the  outer  angle  of  the  wound  and  permitting 
the  vas  deferens  to  lie  undisturbed.  This  method  was  finally 
abandoned  by  Bloodgood  and  other  members  of  the  staff  who 
had  practiced  it,  because  the  subtraction  of  the  vas  deferens 

(5) 


[309]  did  not  appreciably  reduce  the  size  of  the  cord;  furthermore, 
there  were  one  or  two  recurrences  at  the  site  of  the  trans- 
planted veins.  This  is  a  particularly  good  confirmation  of 
the  author's  belief  that  the  veins  are  largely  responsible  for 
the  development  of  oblique  inguinal  hernia.  The  vas  deferens 
contributes,  relatively,  very  little  to  the  size  of  most  adult 
cords,  but  the  veins,  which  at  one  moment  make  a  bundle  as 
large  as  one's  linger,  may  the  next  and  when  empty  be  reduced 
to  the  size  of  a  small  quill.  Is  not  this  variation  in  the  size 
of  the  cord  possibly  a  factor  in  the  production  of  hernia? 
When  the  hernia  is  first  developing  and  the  sac  is,  at  opera- 
tion, inside  the  internal  abdominal  ring,  it  can  readily  be 
demonstrated  by  a  little  pull  on  the  veins.  The  fat,  too, 
which  is  recognized  as  sometimes  a  probable  factor  in  the  pro- 
duction of  hernia,  accompanies  for  a  short  distance  the  veins 
rather  than  the  vas  deferens.  This  fat  when  present  should 
be  excised  with  the  veins.  For  several  years,  then,  we  have 
been  excising  the  veins  in  this  careful  manner,  leaving  the  vas 
deferens  untransplanted,  undisturbed,  and  the  internal  oblique 
muscle  undivided.  In  a  few  cases,  however,  without,  that  I 
am  aware  of,  ultimate  damage  to  the  testicle,  we  transplanted 
the  vas  deferens  to  the  outer  angle  of  the  wound.  But  we  are 
quite  certain  that,  as  a  rule,  the  less  the  vas  deferens  is  mani- 
pulated and  the  more  carefully  the  veins  are  excised,  the  less 
is  the  subsequent  congestion  of  the  epididymis.  It  is  instruc- 
tive from  day  to  day  to  study  the  stump  of  the  veins,  the 
epididymis,  the  testicles,  etc.,  after  operations  for  hernia. 

It  is  not  the  purpose  of  this  communication  to  give  the  re- 
sults in  detail  of  these  observations. 

In  a  recent  private  case,  urethritis  Neisseri  made  its  appear- 
ance a  few  hours  after  the  operation.  We  naturally  watched 
the  epididymis  on  the  operated  side  with  some  concern,  fear- 
ing that  excision  of  the  veins  might  lower  the  resistance  of 
this  organ.  On  the  twelfth  day,  without  warning,  a  very  slight 
induration  of  the  epididymis  became  evident.     T  attributed 

[310]  tliis  to  the  fact  that  the  patient  carried  out  his  irrigation- 
treatment  badly,  for  the  proper"^  method  of  irrigation  being 


6  When  the  author's  method  of  treating  gonorrhoea  can  fail  in  his  own 
wards,  because  improperly  understood,  it  is  not  strange  that  so  admir- 

(6) 


instituted,  the  swelling  of  the  epididymis  immediately  sub-  [2i0] 
sided  and  the  urethral  discharge  promptly  ceased. 

Four  years  ago  the  author  used,  for  the  first  time,  a  part  of 
the  aponeurosis  covering  the  right  rectus  muscle  to  close  the 
lower  part  of  the  right  inguinal  canal.  I  felt  compelled  in 
this  case  to  resort  to  some  such  measure,  for  the  internal  ob- 
lique was  fatty  and  attenuated  to  a  degree  not  very  often  seen 
by  us,  and  the  rectus  muscle  did  not  seem  to  promise  so  much 
as  its  fascia  did.  This  patient  was  a  college-mate  of  mine 
and  for  this  reason  I  wished,  perhaps,  more  than  ever,  to  be 
very  sure  of  the  result.  One  year  ago  I  examined  this  patient 
very  carefully  and  was  gratified  to  find  as  solid  a  closure  as 
one  could  desire.  I  considered  the  result  as  perfect  as  any 
that  I  had  seen.  Dr.  Harvey  Gushing,  house  surgeon  at  the 
time,  made  a  sketch  of  this  act  of  the  operation,  which  Brodel 
has  kindly  elaborated  (vide  Fig.  VII).  This  procedure  may 
have  a  wider  application  than  I  have  proposed  for  it.     The 


able  a  surgeon  as  Dr.  Orville  Horwitz,  apropos  of  Janet's  work  on  the 
abortive  treatment  of  gonorrhoea  by  permanganate  of  potash,  should 
write  :  "In  spite  of  the  claim  of  quick  cures  and  prevention  of  complica- 
tions a  length  of  time  elapsed  before  it  began  to  be  generally  adopted  in 
this  country.  The  profession  was  skeptical  as  to  the  claims  made  for 
its  brilliant  results.  This  was  probably  due  to  the  disappointment 
which  had  followed  the  employment  of  retroinjections  of  hot  water  sug- 
gested by  H.  Holbrook  Curtis,  and  of  the  continuous  irrigation  with  a 
hot  solution  of  mercury  bichloride,  recommended  by  Dr.  W.  S.  Halsted, 
which  at  the  outset  seemed  to  offer  more  benefit  to  the  patient  than  the 
conservative  methods  then  in  vogue,  but  resulting  after  a  fair  trial  by 
a  large  number  of  observers  in  being  found  valueless  and  often  danger- 
ous ;  the  employment  of  these  remedies  having  been  found  to  be 
attended  with  great  discomfort  to  the  patient  and  being  frequently  ac- 
companied by  severe  complications,  such  as  acute  posterior  urethritis, 
seminal  vesiculitis,  prostatitis,  and  cystitis."  This  is  not  the  proper 
time  to  tell  how  one  must  use  the  bichloride  solutions  in  order  to  obtain 
the  best  results  which  have  been  claimed  for  it,  but  to  judge  from  my 
own  experience  with  this  method  twenty  years  ago  in  private  practice, 
too  much  has  hardly  been  said  in  its  favor.  The  bad  and  indifferent 
results  probably  come  from  mismanagement  or  misconception.  I  should 
be  glad  at  some  future  time  to  publish  the  treatment  in  detail,  for  it 
happens  that  I  have  not  heretofore  described  or,  in  print,  claimed  any- 
thing for  the  method  which  rightly  bears  my  name.  I  agree  with  Dr. 
Horwitz  that  irrigation  with  hot  water  is  not  only  useless  but  dangerous. 

(7) 


[310]  anterior  sheath  of  the  rectus  muscle  might  be  employed  in 
the  way  described  whenever  the  conjoined  tendon  is  insuffi- 
cient, whether  the  cremaster  muscle  can  be  well  used  to  rem- 
edy the  defect  or  not.  And  Berger'  has  recently  suggested 
using  the  rectus  sheath  in  much  the  same  way  in  operations 
for  the  cure  of  inguino-interstitial  hernia. 

In  the  upper  part  of  the  canal  we  have  strong  tissues  and 
plenty  with  which  to  close,  and  hence  it  was  perhaps  natural 
to  transplant  the  cord  to  the  upper  angle,  to  bring  it  out 
through  thick  muscle.  But  it  is  not  perfectly  certain  that  the 
cord  may  not  be  a  useful  adjunct  in  the  closing  or  filling  in  of 
the  lower  angle  in  some  cases,  and  it  is  a  fact  that  with  Bas- 
sini's  operation  the  percentage  of  recurrence  at  the  position  of 
the  transplanted  cord  in  the  case  of  adults  has  been  quite  large, 
probably  over  6  per  cent.  Wliatever  the  truth  may  be,  we 
have  in  the  excision  of  the  veins  a  distinct  contraindication  to 
transplanting  the  vas  deferens,  and  thus  far  we  have  had  no 
reason  to  believe  that  the  results  would  have  been  better  if  the 
vas  deferens  had  been  transplanted,  as  was  our  custom  for  sev- 
eral years,  to  the  outer  angle  of  the  canal.  We  may  eventually 
discover  that  the  transplantation  of  the  cord,  which  Bassini, 
and  at  one  time  the  author,  considered  not  only  so  important, 
but  perhaps  the  principal  feature  of  the  operation,  is  harm- 
ful rather  than  helpful.  Briefly,  we  may  find  that  not  only 
the  vas  deferens,  but  even  the  entire  cord,  would  be  more  safely 
transmitted  at  the  lower  angle  of  the  deep  wound  than  at  the 
upper.  It  would  require  a  very  large  number  of  observations 
to  determine  this  point  because  the  percentage  of  recurrences  is 
so  small  in  these  days;  and  it  is  unfair  to  compare  the  results 
of  various  operations  in  the  hands  of  various  operators.  Sur- 
geons do  not  seem  to  be  agreed  even  as  to  what  shall  constitute 
a  recurrence,  or  wound  suppuration,  and,  if  they  were  agreed, 
the  personal  element  would  still  count  for  much. 

The  Use  of  ihe  Cremaster  Muscle. — A  device  which  we  hit 
upon  in  our  efTorts  to  close  more  securely  the  lower  part  of  the 


^P.  Berger:     La.  Hernie  ingiiino-interstielle  et  son  traitement  par  la 
Cure  radicale.     Revue  de  Chirurgie,  Janvier,  1902. 

(8) 


canal,  but  which  we  now  make  use  of  as  often  as  feasible,  [210] 
probably  in  over  75  per  cent  of  the  cases,  is  the  utilization  of  at 
least  a  part  of  the  cremaster  muscle,  which  we  formerly  cut 
away.  This  is  a  step  of  the  operation  to  which  one  is  irresist- 
ibly drawn  in  some  cases  by  the  great  strength  of  the  cremas- 
ter and  the  firmness  and  extent  of  its  attachments  to  Poupart's 
ligament.  A  natural  insertion,  such  as  this,  of  the  cremaster 
and  its  fascia  into  Poupart's  ligament,  has  in  each  case  a  value 
which  can  be  demonstrated  on  the  operating  table  and  can  be 
counted  upon  definitely  to  contribute  something,  and  occa- 
sionally perhaps  a  great  deal,  to  the  strength  of  the  abdominal 
wall;  whereas  the  artificial  insertion  of  the  internal  oblique 
into  Poupart's  ligament,  although  undoubtedly  of  the  utmost 
importance  and  always  to  be  tried  for,  may  occasionally  and 
perhaps  often  fail,  from  insufficient  muscle,  too  great  tension, 
or  gradual  redressment,  to  close  securely  even  the  upper  part 
of  the  canal.  The  lower  part  of  the  canal,  ordinarily  pro- 
tected by  the  conjoined  tendon,  can  rarely  be  entirely  safe- 
guarded by  the  muscle  fibres  of  the  internal  oblique  when  its 
conjoined  tendon  is  deficient.  The  cremaster,  on  the  other 
hand,  seems  in  just  these  cases  to  serve  a  particularly  good 
purpose.  The  cremaster,  unaided,  has  repeatedly  made  such  a 
complete  and  strong  looking  closure  that  we  have  felt  the 
hernia  would  be  well  cured  if  the  operation  were  abandoned  at 
this  stage. 

I  have  today,  June  10,  1903,  examined  a  patient  whose  very 
wide  inguinal  canals  (the  gap  would  have  admitted  the  hand) 
were  closed  eighteen  months  ago  solely  by  the  cremasters 
stitched  over  instead  of  under  the  internal  oblique  muscle; 
the  result,  in  the  opinion  of  those  who  examined  the  case,  is 
absolutely  perfect,  on  both  sides.  My  house  surgeon.  Dr.  Fol- 
lis,  and  one  or  two  others  examined  the  man''  with  me.     Even  [sii] 


^The  history  is  briefly  this.  Male,  fet.  59  years;  Surgical  No.  12,905  ; 
was  operated  upon  January  15,  1902,  for  two  very  large  scrotal  ruptures, 
eighteen  and  twenty-four  inches  long  (from  external  ring  to  bottom  of 
scrotum).  The  conjoined  tendons  on  both  sides  were  almost  obliterated. 
The  circumcentral  rings  easily  admitted  four  fingers.  The  cremaster 
muscles,  very  well  developed,  were  used  to  close  the  entire  dehiscence 
because  the  internal  oblique  muscles  could,  only  with  great  tension,  be 

(9) 


1211]  had  I  known  what  the  result  in  this  case  was  to  be,  I  would 
have  used,  if  possible,  the  internal  oblique  muscles  in  the  old 
way,  and  hence  have  stitched  the  cremaster  under  rather  than 
over  the  former.  But  the  muscles  were  attenuated  and  not 
close  at  hand.  Stitching  the  cremaster  over  the  internal  ob- 
lique muscle  necessarily  precludes  the  sewing  of  the  latter  to 
Poupart's  ligament.  The  closure  with  the  cremaster  seems 
almost  ideal  in  some  cases ;  it  is  a  method  so  inviting  during 
the  operation,  and  so  true,  when  finished,  to  one  of  the  great 
principles  of  surgery;  there  is  no  tension.  It  is,  in  this 
respect,  as  a  plastic  operation  should  be.  What  the  ultimate 
verdict  will  be  it  is  too  soon  to  predict.  The  cremaster  fibres, 
particularly  the  hypertrophied  ones,  will,  in  time,  atrophy; 
but  when  this  occurs,  the  cremasteric  fascia,  perhaps  stronger 
than  before,  would  probably  remain,  holding  together  the  atro- 
phied muscle  bundles.  There  can,  at  least,  no  harm  result 
from  this  attempt  to  strengthen  the  wall,  for  the  internal 
oblique  muscle  has  been  used  in  the  usual  manner.  The  worst 
that  could  happen  would  be  a  recurrence,  in  a  certain  class  of 
cases,  at  the  lower  angle,  one  that  might,  possibly,  have  been 
avoided  if  the  aponeurosis  over  the  rectus  muscle  had  been 
employed  instead  of  the  cremaster  as  described  by  the  author. 
The  future  will  decide  these  nicer  points,  and  it  would  seem 
that  only  the  nicer  points  remain  now  to  interest  the  operator. 

Another  feature  of  the  present  operation  is  to  transplant 
the  neck  of  the  sac  as  described  below.  It  is  merely  an  addi- 
tional precaution  warranted  by  the  good  results  obtained  by 
Kocher  and  others  with  his  operation. 

And,  finally,  we  overlap  the  aponeurosis  of  the  external  ob- 
lique muscle  to  insure  the  union  which  a  mere  approximation 
of  the  edges  of  the  aponeurosis  cannot  do,  and  to  close  more 
snugly  the  external  ring. 

We  still  examine  with  the  same  care,  but  no  longer 
with  concern,  the  epididymis,  testicle,  stump  of  veins,  etc., 
chiefly  to  ascertain  if  there  is  congestion    (induration)    of 


drawn  down  to  Poupart'a  ligament;  the  former  was  stitched  in  front  of 
instead  of  behind  the  latter  muscles.  We  had  never  before  and  have 
never  since  had  occasion  to  use  the  cremasters  in  this  way.  Dr.  Mitchell, 
my  house  surgeon,  operated  upon  one  side,  and  the  author  upon  the  other. 

(10) 


THE  JOHNS   HOPKINS   hlOSPITAL   BULLETIN,   AUGUST,    1903.        PLATE  XIV. 


Fig.   I. 


Fi<;.    in. 


THE  JOHNS   HOPKINS   HOSPITAL   BULLETIN,   AUGUST,   1903.        PLATE  XIV. 


Fig.  II. 


[    yyi-3-    03 


Fro.  IV 


THE  JOHNS   HOPKINS   HOSPITAL   BULLETIN,   AUGUST,   1903.         PLATE  XV. 


1  n  t  er  n  a  1  ^^Sjj^^ 

ni    - 
^~~-   U          ApoTieurobis  of 

Cremaster--' 

^^^^^^^ 

■';!-^-;'       "^  ^.,..u 

Fig.  V 


Fio.  vr. 


THE  JOHNS   HOPKINS   HOSPITAL  BULLETIN,  AUGUST,   1903.         PLATE  XV. 


Fig.  VII. 


the  epididymis  or  fluid  in  the  tunica  vaginalis.  Often  there  [2ii] 
is  an  appreciable,  though  very  slight,  induration  of  the  epi- 
didymis, particularly  if  the  veins  have  been  ligated  through 
the  dense  plexus  very  near  the  testicle;  and  often  a  few 
drops  or  a  drachm  or  two,  or  even  more  fluid  is  present  in  the 
tunica  vaginalis.  This  may  become  absorbed  in  a  few  weeks 
or  months  and  might,  when  present,  usually  not  be  noticed  by 
the  patient  except  for  the  repeated  careful  examinations.  Hy- 
droceles containing  several  ounces  have  been  recorded  in  our 
histories;  in  two  or  three  instances  operation  for  the  cure  of 
the  hydrocele  has  been  performed.  What  the  proportion  of 
hydroceles  is  to  the  cases  operated  upon  for  the  cure  of  hernia, 
without  vein  excision,  I  cannot  say  for  the  reason  that  we  ex- 
cise the  veins  almost  invariably  nowadays,  and  in  the  days 
when  the  veins  were  not  excised  we  did  not  observe  our  cases 
quite  so  keenly  with  reference  to  this  point.  One  of  the 
larger  hydroceles  followed,  as  I  have  said,  an  operation  in 
which  the  veins  were  neither  excised  nor  transplanted  nor  in 
any  way  disturbed.  The  patient,  a  navy  officer,  had  an  indi- 
rect rupture  on  each  side.  Both  sides  were  operated  upon  at 
the  same  time  and  on  both,  hydroceles  developed  in  a  few  days, 
although  neither  epididymis  became  more  than  just  perceptibly 
indurated ;  but  the  larger  hydrocele  was  on  the  side  of  the  un- 
disturbed veins  and  of  the  smaller  hernia.  Not  a  single  atro- 
phy of  the  testicle  has  been  recorded  since  1899,  when  Blood- 
good-^ublished  his  report,  and  I  believe  that  at  that  time  it 
was  noted  that  not  one  had  been  observed  for  several  years. 

Possibly  some  of  my  readers  will  ask,  "  Why  take  so  much 
trouble,  why  make  the  operation  so  complicated  when  such 
good  results  as  are  published  may  be  obtained  by  simpler 
methods  ?"  The  operation  is  not  complicated  for  the  surgeon 
competent  to  operate  for  the  cure  of  hernia,  nor  are  all  its 
details  required  for  the  simpler  cases,  and  we  do  not  know 
just  what  the  results  obtained  by  simpler  methods  are.  We 
cannot  ascertain  definitely  even  our  own  results,  although  we 
make  a  great  effort  and  are  admirably  equipped  to  do  so.  This 
can  be  said,  however,  that,  since  the  publication  of  the  author's 
second  paper,  June,  1892,  not  a  single  recurrence  has  been 

•     (11) 


1211]  charged  to  him.  One  of  the  world's  most  distinguished  sur- 
geons, the  inventor  of  a  clever  hernia  operation,  made,  with 
reference  to  himself,  some  such  remark  to  the  author  three  or 
four  years  ago,  and  the  next  morning  two  recurrences  pre- 
sented themselves.  This  surgeon  permits  his  patients  to  get 
out  of  bed  in  eight  days  because,  as  he  said  to  me,  "A  man 
can  better  afford  to  be  operated  upon  three  or  four  times  for 
recurrence  by  my  method  than  once  by  a  method  like  Mc- 
Ewen's,  which  requires  lying  in  bed  for  five  or  six  weeks."  In 
my  exj^erience  a  man  would,  after  operation,  prefer  to  spend 
several  additional  weeks  in  bed  than  run  the  risk  of  a  recur- 
rence. It  is  only  before,  not  after  the  operation  that  a  patient 
objects  so  vigorously  to  the  time  to  be  spent  in  bed. 

The  Operation. — The  several  steps  of  the  operation  are  so 
well  depicted  by  the  illustrations  of  Brodel  that  a  verbal  de- 
scription is  almost  superfluous  for  those  who  have  the  plates. 

(I)  The  aponeurosis  of  the  external  oblique  muscle  is  di- 
vided and  the  two  flaps  reflected  as  in  the  Bassini-Halsted  op- 
eration. 

(II)  The  cremaster  muscle  and  fascia  is  split,  not  directly 
over  the  centre  of  the  cord,  but  a  little  above  it. 

(III)  The  internal  oblique  muscle  is  made  as  free  as  pos- 
sible. A  little  artef action  is  here  often  necessary.  If  the  mus- 
cle cannot  be  drawn,  without  tension,  well  down  to  Poupart's 
ligament,  it  helps,  I  think,  to  make  a  relaxation  cut  or  two  in 
the  anterior  sheath  of  the  rectus  muscle  under  the  aponeurosis 
of  the  external  oblique  muscle.     This  sheath  being  in  part  the 

[212]  aponeurosis  of  the  internal  oblique  muscle,  one  can  readily 
comprehend  that  incisions  into  it,  if  properly  made,  might  be 
of  service.  It  is  M'ell,  however,  to  postpone  making  such  in- 
cisions until  the  sewing  of  the  internal  oblique  muscle  to  Pou- 
part's ligament  is  begun,  for  then  the  amount  of  tension  can  be 
nicely  gauged  and  the  number,  length  and  precise  position  of 
the  relaxation  cuts  determined.  A  second  reason  for  postpon- 
ing the  relaxation  incisions  into  the  anterior  sheath  of  the 
rectus  muscle  is  that  we  sometimes  use  this  portion  of  the 
rectus  sheath  to  close  the  lower  port  of  the  inguinal  canal,  as 
already  stated. 

(13) 


(IV)  When  the  veins  arc  large,  and  this  is  usually  the  case,  [313] 
they  should  be  excised  with  very  great  care  to  avoid  even  the 
slightest  extravasation  of  blood  into  the  tissues  about  the 
smaller  veins  and  about  the  vas  deferens  which  they  accom- 
pany. And  the  vas  deferens,  as  first  emphasized  by  Blood- 
good,  should  not  be  raised  from  its  bed  or  handled  or  even 
touched,  lest  thrombosis  of  its  veins  occur.'  (Vide  Fig.  VI.) 
The  veins  should  be  ligated  as  high  up  in  the  abdomen  as  pos- 
sible, being  pulled  down  quite  firmly  just  before  the  ligature 

(in  a  needle  with  the  blunt  end  first)  is  passed  between  them. 
As  a  precaution  against  slipping,  we  apply  two  ligatures  of 
fine  silk,  both  for  the  abdominal  stump  and  for  the  testicle 
stump  of  the  veins.  The  farther  from  the  testicle  the  veins 
are  divided,  the  better,  provided,  of  course,  that  their  stump  is 
external  to  the  external  abdominal  ring. 

(V)  Ligation  of  the  sac  by  transfixion  or  by  purse  string 
suture  at  the  highest  possible  point.  Both  ends  of  this  suture, 
after  tying,  are  threaded  on  long  curved  needles,  then  carried 
far  out  under  the  internal  oblique  muscle  from  behind  for- 
wards, and,  passing  through  this  muscle,  about  5  mm.  apart, 
are  tied.  The  idea  was  suggested  to  the  author  by  Kocher's 
operation,  the  principle  being  essentially  the  same." 

(VI)  The  lower  fiap  of  the  cremaster  muscle  and  its  fascia 
is  drawn  up  under  the  mobilized  internal  oblique  muscle  and 
held  in  this  position  by  very  fine  silk  stitches,  which,  having 
engaged  firmly  a  few  bundles  of  the  cremaster,  perforate  the 
internal  oblique,  preferably  where  it  is  becoming  aponeurotic, 
and  are  tied  on  the  external  surface  of  the  latter ;  vide  Fig.  I. 

(VII)  The  internal  oblique  muscle,  mobilized,  and  possibly 
further  released  by  incising  the  anterior  sheath  of  the  rectus 
muscle,  is  stitched  (the  conjoined  tendon  also)  to  Poupart's 


''The  fact  is  that  the  vas  deferens  is  frequently  accidentally  handled 
or  squeezed,  but  harm  that  we  know  of  has  never  resulted  since  we  have 
recognized  the  necessity  for  exercising  great  care  in  the  separation  and 
ligation  of  the  veins. 

3  I  have  read  recently  in  the  Centralblatt  fiir  Chirurgie  a  reference  to 
some  other  surgeon's  account  of  this  very  procedure,  but,  unfortunately, 
cannot  recall  the  surgeon's  name  and  have  not  the  facilities  at  this 
moment  to  hunt  for  it. 

(13) 


[212]  ligament  in  the  Bassini-Halsted  manner.  (Vide  Fig.  11.) 
Catgut  is  usually  employed  for  this  suture.  The  drawing 
was  made  from  an  unusually  muscular  subject  and  possibly 
exaggerated  the  size  and  extent  of  the  internal  oblique  mus- 
cle, as  well  as  of  the  cremaster,  although  the  artist  endeavored 
to  record  accurately  what  he  saw. 

(VIII)  The  aponeurosis  of  the  external  oblique  muscle  is 
overlapped,  as  shown  in  Figs.  Ill  and  IV.  This  is  known  as 
Andrew's  "  method,  although  devised  independently  by  us. 

(IX)  The  skin  is  closed  with  a  buried  continuous  silver 
suture,  and  the  incision  covered  with  five  or  six  layers  of  silver 
foil.  It  is  unnecessary  to  dress  or  examine  a  wound  closed  in 
this  manner  for  two  weeks,  when  the  wire  may  be  withdrawn. 
Patients  are  kept  in  bed  from  eighteen  to  twenty-one  days. 

We  hope  to  be  able  to  publish  very  soon  the  results  of  the 
first  1000  operations  performed  for  the  cure  of  inguinal  hernia 
at  the  Johns  Hopkins  Hospital.  Certainly  more  than  two- 
thirds  of  the  operations  have  been  performed  by  my  associates, 
Drs.  Finney,  Bloodgood,  Cushing,  Mitchell  and  Follis,  for  we 
are  all  much  interested  in  the  subject.  Each  operator  has  been 
at  perfect  liberty  and  is  encouraged  to  perform  the  operation 
according  to  his  best  judgment.  This  fortunately  furnished 
a  little  variety,  but  of  late  the  operation  has,  in  almost  every 
detail,  been  performed  just  as  the  writer  has  described  it. 

Inasmuch  as  only  a  limited  number  of  surgeons  see  the 
Johns  Hopkins  Hospital  Eeports,  in  which  Dr.  Bloodgood 
published  his  article,  it  may  be  well  to  publish  one  or  two  of 
the  Summaries  which  he  prepared  with  such  care  and  so  great 
labor.  He  intends  quite  soon  to  investigate  the  condition  of  all 
those,  so  far  as  possible,  who  are  included  in  these  Summaries. 

"  Summary   of   the   Ultimate   Eesults.      Complete    to 
June  1,  1899.'^ 

"  Eecent  cases,  less  than  6  months,  and  cases  lost  track  of 
were  not  included. 


10  The  Chicago  Medical  Recorder,  August,  1895,  vol.  ix,  p.  67. 

(14) 


All  cases  Group  I  to  Y  healing  p.  p.. 301  cases.    13  recur.  4.3^  [212] 
All  cases  Group  I  suppurating 31     "  9    "        29^ 

Total 332     "         22    "       6.6^ 

Halsted's  operation,  Group  I,  healing 

p.  p 218  cases.     9  recur.  4.1^ 

Halsted's  operation,  Group  I,  suppu- 
rating      20     "  6    "        30^ 

Total,  Group  1 238     "         15    "       6.2^ 

"  Eecurrence  in  Wounds  Healing  Per  Primam." 

Cases.  Recurrences. 

(1)  'At  the  position  of  the  transplanted 

cord,  veins  excised 109  nil. 

(2)  At  the  position  of  the  transplanted 

cord,  veins  not  excised 109  7  (6.4^) 

(3)  Upper  angle  of  the  wound,  cord  ex- 

cised or  not  transplanted 83  1(1. 2^) 

(4)  Lower   angle   of   the   wound,    con-  [2i3i 

joined  tendon  wide  and  firm,  rec- 
tus muscle  not  transplanted 264  nil. 

(5)  Lower   angle   of   the   wound,   con- 

joined tendon  obliterated,  rectus 

muscle  not  transplanted 8  5(6 2^) 

(6)  Lower   angle   of   the   wound,    con- 

joined tendon  obliterated,  rectus 

muscle  transplanted  14  nil. 

(7)  Lower   angle    of   the   wound,   con- 

joined tendon  wide  and  firm,  rec- 
tus muscle  transplanted 16  nil. 

"  Eecurrence  in  Wounds  Healing  by  Suppuration.''' 

(1)   At  the  position  of  the  transplanted 

cord,  veins  excised 9  nil. 

(15) 


[313] 


Cases.         Recurrences. 

(2)  At  the  position  of  the  transplanted 

cord,  veins  not  excised 11  4  (36.3^) 

(3)  Upper  angle  of  the  wound,  cord  ex- 

cised or  not  transplanted 11  1(9^) 

(4)  Lower  angle   of   the   wound,   con- 

joined tendon  wide  and  firm,  rec- 
tus muscle  not  transplanted 27  2  (7.4^) 

(5)  Lower   angle   of   the    wound,   con- 

joined tendon  obliterated,  rectus 

muscle  not  transplanted 4  2  (50;^) 

Dr,  Bloodgood's  "  Conclusions  as  to  the  operation  for  in- 
guinal hernia''  published  in  1899  : 

"  Our  observations  prove  that  Halsted's  operation  with  the 
excision  of  the  veins  will  give  perfect  results,  except  in  those 
few  cases  in  which  the  conjoined  tendon  is  obliterated;  in 
these  cases  our  observations  so  far  have  demonstrated  that  the 
transplantation  of  the  rectus  muscle  will  give  perfect  results." 

"  If  the  veins  could  be  excised  in  every  case  of  inguinal  her- 
nia and  the  remainder  of  the  cord  transplanted  without  any 
risk  of  epididymitis  and  atrophy  of  the  testicle,  a  perfect  re- 
sult would  probably  be  accomplished  in  every  case." 

"  The  operation  would  then  be :  The  ligation  and  excision 
of  the  veins,  the  transplantation  of  the  remaining  portion  of 
the  cord  into  the  upper  angle  of  the  divided  and  transplanted 
internal  oblique  muscle,  and,  in  cases  in  which  the  conjoined 
tendon  is  obliterated,  the  transplantation  of  the  rectus  m^uscle. 
So  far  we  have  not  observed  a  single  recurrence  when  these 
procedures  have  been  adopted.  The  sole  objection  to  this 
method  is  the  danger  of  atrophy  of  the  testicle  after  excision 
of  the  veins.  Atrophy  of  the  testicle  has  been  observed  only 
after  a  very  marked  epididymitis.  The  probabilities  of  this 
epididymitis  are  very  much  less  when  the  veins  are  excised 
without  disturbing  the  vas  deferens  and  its  immediate  vessels. 
For  this  reason  I.  should  advise  that  when  the  veins  are  ex- 
cised the  remainder  of  the  cord,  a  very  small  affair,  be  left 
undisturbed.     I  am  very  much  inclined  to  believe  that  the 

(16) 


cord,  reduced  to  such  a  diminutive  size  by  the  excision  of  the  [313] 
veins,  will  be  as  little  likely  to  be  the  cause  of  a  recurrence  in 
the  lower  angle  of  the  wound  as  in  the  upper  angle  when  it  is 
transplanted/' 

"  Cases  in  which  the  Veins  should  not  he  Excised." 
"When  during  the  dissection  of  the  sac  the  cord  is  torn 
from  its  bed  in  the  inguinal  canal  and  subjected  to  trauma- 
tism, and  the  testicle  withdrawn  from  the  scrotum,  the  veins 
should  not  be  excised,  because  the  probabilities  of  epididymitis 
and  atrophy  are  too  great.  In  such  cases  I  would  advise  the 
transplantation  of  the  veins  alone,  so  that  the  larger  cord  is 
divided,"  and  the  wound  is  weakened  less  by  the  presence  of  a 
very  small  cord  in  two  places  than  by  the  presence  of  a  larger 
cord  in  one  place,  which  from  our  results  we  know  to  have 
been  the  cause  of  a  recurrence  in  6.4  per  cent  of  the  cases.'' 

"Xote,  June,  1899.  In  October,  1898,  I  performed  for 
the  first  time  the  splitting  of  the  cord,  transplanting  the  veins 
only.  Since  this  date  the  modification  has  been  followed  in 
26  operations  for  inguinal  hernia.  In  12  the  rectus  muscle 
was  transplanted.  The  wounds  in  25  cases  healed  per 
primam.  In  19  cases  no  swelling  of  the  testicle  followed  op- 
eration. In  7  cases  there  was  slight  but  temporary  swelling. 
Thrombosis  of  the  veins  was  not  observed  in  any  of  the  26 
cases.  It  is  seven  months  since  the  first  two  operations.  Both 
are  perfect  results.     The  others  are  recent  operations." 

"  When  the  bundle  of  veins  is  unusually  large,  and  complete 
excision  is  contra-indicated  for  reasons  already  given,  I  have 
suggested  that  a  portion  should  be  ligated  and  excised  and  the 
remainder  transplanted.  This  has  been  done  in  a  recent  case 
by  Doctor  Gushing." 

"In  children  the  veins  should  not  be  excised;  the  proba- 
bility of  atrophy  is  greater  than  in  adults.  As  we  have  had  no 
recurrences  whether  veins  have  been  excised  or  not,  it  does  not 
seem  to  make  much  difference  what  is  done  with  the  very  small 
cord." 


"The  splitting  of  the  cord  has  been  discontinued  by  its  author. 

(17) 


[313]  "  In  the  female  the  round  ligament  and  its  vessels  is 
such  a  small  affair  that  it  makes  little  difference  what  is  done 
with  it." 

"References  to  the  transplantation  of  the  rectus  muscle  by 
Wofler:  Wofler  published  his  method  of  transplantation  of 
the  rectus  in  1892  in  the  Beitrage  z.  Festschrift  f.  Th.  Bill- 
roth. I  did  not  see  this  publication  until  my  colleague,  Dr. 
Clark,  returned  from  Germaiiy,  in  June,  1898.  My  prelimi- 
nary report  had  then  just  been  published.  For  this  reason  no 
mention  was  made  of  Wofler's  work.  In  the  Archiv  fiir  klin- 
ische  Chirurgie,  June,  1898,  Dr.  Slajmer  publishes  150  opera- 
tions after  the  Wofler  method.  A  careful  reading  of  these 
two  articles  has  convinced  me  that  this  method  of  transplan- 
tation of  the  rectus  differs  from  mine.  In  the  first  place  no 
special  reasons  are  given  for  the  transplanting  of  the  rectus 
muscle,  while  in  my  publication  the  reason  given  for  the 
transplantation  of  the  rectus  is  to  strengthen  the  lower  por- 

[214]  tion  of  the  inguinal  canal  by  the  introduction  of  muscle  which 
is  weakened  by  the  obliteration  of  the  conjoined  tendon.  The 
description  of  the  Wofler  method  and  the  illustration  on  page 
912  of  the  second  article  show  that  the  rectus  muscle  is  not 
transplanted  in  the  best  way  to  strengthen  the  lower  portion 
of  the  wound,  because  the  sheath  of  the  rectus  is  not  divided 
down  to  the  symphysis  pubis ;  but  the  division  of  the  sheath 
ends  at  least  2  to  3  cm.  above  the  pubic  bone.  For  this  rea- 
son the  transplanted  rectus  muscle  is  approximated  chiefly 
over  the  upper  two-thirds  of  the  wound.  In  addition,  Wofler 
divides  the  sheath  of  the  rectus  on  the  anterior  surface  above 
the  linea  semilunaris.  In  my  method  the  sheath  of  the  rectus 
is  divided  posteriorly  and  the  belly  of  the  muscle  is  brought 
out  behind  the  internal  oblique.  I  believe  that  by  this  method 
the  muscle  can  better  be  transplanted  so  as  to  occupy  the 
lower  two-thirds  of  the  wound.  Slajmer  reports  6  recur- 
rences, about  6  per  cent.  In  three  of  these  cases  the  wound 
suppurated." 


(18) 


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